Ralph, a 15-year-old boy, is brought to the emergency room by his mother after she noticed him acting “goofy and drunk.” She reports that his eyes are often bloodshot. His chart lists conduct disorder, cannabis use, and chronic truancy. During the interview, he appears distracted and restless, with a faint chemical odor on his clothing; routine toxicology screens are negative.

Inhalant misuse has been described in the psychiatric literature for decades but remains underrecognized in clinical practice. One reason is deceptively simple: Most inhalants are legal, inexpensive, and easily accessible household or commercial products. Another is that the effects of inhalants are short-lived and typically evade detection on toxicology screens. Despite these barriers to recognition, inhalants carry substantial medical and psychiatric risks, including sudden death. Epidemiologic data suggest that approximately 70% of individuals with inhalant use disorder have a co-occurring psychiatric condition (Cojanu A, Am J Psychiatr Rehabil 2018;130203).

Inhalants are often the first substances misused by adolescents and younger children, particularly those with limited access to alcohol or illicit drugs. But misuse is not limited to youth—adult use occurs and may be underappreciated in general psychiatric settings. Inhalants should be included in routine substance use screening, particularly when clinical clues are present.

This article covers how to identify inhalant use, understand the risks, and offer effective treatment and harm reduction strategies.

How are inhalants used?

Inhalants produce psychoactive effects through inhalation of chemical vapors. Common methods include:

• Sniffing directly from an open container
• “Huffing” by soaking a cloth and holding it to the face
• “Bagging” by inhaling the vapor from a plastic or paper bag

Effects typically begin within seconds and may include euphoria, disinhibition, dizziness, and perceptual disturbances. These effects dissipate quickly, often leading users to repeat inhalation multiple times in a single session to maintain intoxication (Radparavar S, Perm J 2023;27(2):99–109). Repeated exposure increases the risk of both acute toxicity and cumulative harm.

Types of inhalants

Although many substances can be misused as inhalants, they are generally grouped into three categories by type and mechanism:

• Volatile solvents and gases: Hydrocarbons (eg, lighter fluid, gasoline) and products like paint thinner, nail polish remover, hair spray, spray paint, and compressed “air” for dust removal
• Inorganic anesthetic gases: Nitrous oxide (commonly called whippets, NOS, laughing gas, or galaxy gas) obtained from whipped cream canisters; users are increasingly also obtaining it from large cartridges marketed for culinary use
• Nitrites (poppers): A distinct group primarily used for sexual enhancement, sometimes sold legally in adult stores

Volatile solvents and gases exert alcohol-like effects: disinhibition, impaired coordination, and sometimes hallucinations. Nitrites act as vasodilators rather than central nervous system depressants, which distinguishes them pharmacologically from other inhalants. When screening for nitrite use, mentioning multiple examples improves accuracy and normalizes disclosure (Cojanu, 2018; Radparavar, 2023).

Acute and long-term risks

Inhalants may be perceived as benign because they are legal and readily available, but their risks are real and can be fatal.

Life-threatening effects
One of the most feared complications is sudden sniffing death syndrome, in which volatile substances trigger fatal cardiac arrhythmias (Berling I and Isbister GK, Addiction 2025;120(9):1884–1888). Inhalants can also cause hypoxia and aspiration risks heightened by bagging and vomiting. Accidental injuries (eg, falls, burns, and other trauma) are common due to impaired judgment and coordination.

Effects of chronic use
Chronic inhalant use is associated with a broad range of neuropsychiatric effects. Repeated exposure can lead to white matter changes, cognitive impairment, cerebellar dysfunction, and peripheral neuropathy (Lubman DI et al, Br J Pharmacol 2008;154(2):316–326).

Psychiatric sequelae include psychosis, depression, and anxiety. Withdrawal syndrome is characterized by fatigue, palpitations, restlessness, and in some cases seizures (Perron BE et al, Subst Abuse Rehabil 2011;2:69–76).

Beyond the nervous system, chronic inhalant use can adversely affect other organ systems, with effects such as pneumonitis, hepatotoxicity, and bone marrow suppression. Chronic use also has association with hematologic malignancies (eg, leukemia, lymphoma).

Finally, inhalants readily cross the placenta, posing risks to fetal development when used during pregnancy (Radparavar, 2023).

Special risks with nitrous oxide
Nitrous oxide carries the general risks of other inhalants but also poses a unique hazard: It irreversibly inactivates vitamin B12, causing neuropathy and myelopathy that manifest as paresthesias, ataxia, and cognitive and psychiatric symptoms (Swart G et al, Eur J Neurol 2021;28(12):3938–3244).

Clues in the clinical setting
Routine tox screens are usually negative, so rely on the following clues.

Psychiatric signs

• Apathy
• Psychosis
• Anxiety
• Depressive symptoms

Physical signs

• General: Chemical odor on clothing or breath
• Skin: Paint stains, burns, or rash around the mouth and nose
• Eyes: Redness, diplopia, photophobia
• Pulmonary: Cough, dyspnea, wheezing, rhonchi
• Neurologic: Weakness, ataxia, nystagmus, slurred speech

These findings should raise suspicion and prompt you to ask directly about inhalant use.

Screening for inhalant misuse
As with other substance use disorders, clinicians must ask patients about their use directly. Use open-ended, nonjudgmental questions: “Have you ever used products like glue, paint, or spray cans to get high?”

Younger patients or those who seem guarded may respond better to normalization: “Some kids sniff whipped cream cans for a buzz. Have you ever seen that or tried it?”

In adults, inhalant use may present as vague cognitive issues or unexplained neurologic symptoms. Try asking: “Have you ever used cleaning sprays or gas cartridges to get a buzz?”

Assess for immediate safety concerns such as intoxication, airway compromise, or withdrawal requiring urgent attention.

Treating inhalant misuse
There are no FDA-approved medications for inhalant use disorder. We have limited evidence from small studies and case reports that have examined agents such as aripiprazole, haloperidol, carbamazepine, and baclofen, but data are insufficient to recommend pharmacotherapy.

Medical stabilization comes first
The first and most necessary step in treatment is to ensure medical safety. Clinicians in outpatient settings should stay alert for complications that require hospital care. Difluoroethane (the intoxicating ingredient in compressed “air”) can trigger arrhythmias and seizures that may require hospital-level monitoring and supportive care, sometimes even in an ICU.

Among patients using nitrous oxide, new numbness, tingling, or ataxia should prompt evaluation for vitamin B12 deficiency. Severe deficiency can cause subacute combined degeneration (demyelination of the dorsal and lateral columns of the spinal cord, impairing sensation and motor control). These patients may require hospitalization for B12 repletion, neurologic evaluation, and imaging.

Psychosocial approaches
Psychosocial interventions remain the cornerstone of treatment, including psychotherapy, family-based interventions, and residential programs. Motivational interviewing can help build rapport, explore ambivalence, and support behavior change.

Management of comorbid conditions
Mood disorders, anxiety, and psychosis are common in people who misuse inhalants. Once medically stabilized, address these comorbidities as you normally would.

Harm reduction is key
Harm reduction is essential for patients who continue to use inhalants. Encourage them not to use alone and to ensure adequate ventilation. For adolescents, collaboration with school counselors and community supports can help. In some cases, particularly when use places the patient at acute risk, inpatient substance use treatment may be indicated (Lail G et al, Cureus 2025;17(7):e89170).

Maintaining a high index of suspicion, you ask Ralph directly about inhalant use. He admits to sniffing gas from whipped cream cans and appears surprised when you explain the risks. You refer him to an adolescent mental health provider, who plans to initiate psychotherapy and involve his mother closely.

Carlat Verdict: Don’t overlook inhalants. They can cause serious short- and long-term harm. They are not detected on urine drug screens, so ask about them directly and offer education, psychotherapy, and harm reduction strategies.